Crapifying Medicare with the New MACRA Program

By Lambert Strether of Corrente.

Single payer advocates tend to frame the obvious sanity and humanity of their policy proposal as “Medicare for All,” which would be great if “Medicare” meant Canadian Medicare, and not American Medicare, which is suffering from a tenacious neoliberal infestatation and hence, as readers periodically point out to to us, is becoming increasingly crapified. (There’s none of this “free at the point of care” nonsense that curses the Brits; instead, there are still monthly payments, more or less onerous, co-pays, and the increasing complexity and rental extraction that always comes from neoliberal market fundamentalism.) I’ve been reluctant to dig into Medicare, because heaven knows ObamaCare is enough, but prompted by alert reader DCSweeney, I’m going to give it a shot. (And I hope readers will feel free to share their own horror stories experiences in comments.) I also hope that readers more familiar with Medicare policy than I am — many of you, I am sure — will weigh in with clarifications and commentary.

MACRA stands for “Medicare Access and CHIP Reauthorization Act,” and there’s something pleasingly meta, even a foretaste of what is to come, in the fact that “MACRA” is an acronym that includes an acronym (CHIP, Children’s Health Insurance Program). The American Hospital Assocation (not a disinterested player, but that is a topic for another post) summarizes MACRA as follows:

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 makes sweeping changes to how Medicare will pay for physician services. The legislation repeals the flawed Medicare physician sustainable growth rate (SGR) formula and, instead, provides predictable payment increases. The law also calls for the Centers for Medicare & Medicaid Services (CMS) to implement a new two-track payment system for physicians and other eligible professionals. The intent of the two tracks is to tie an increased percentage of physician payments to outcomes through the Merit-based Incentive Payment System [MIPS] and to encourage the adoption of “alternative payment models” (APMs). APMs move payment away from fee-for-service reimbursement, and instead pay providers based on the quality and cost of care for particular episodes (e.g., bundled payment), or defined patient populations (e.g., accountable care organizations).

(MACRA is one of those “bipartisan” bills that gives you the idea that the only thing the two parties can ever agree on is screwing the rest of us.)

Note that MIPS and APMs are separate tracks, and the number of doctors put into MIPS will be an order of magnitude larger than those put into APMs. From Policy and Medicine:

Because of the high bar set to qualify for the APM track, CMS projects that only 30,000 to 90,000 clinicians will be in the APM track. An estimated 687,000 to 746,000 physicians will be in MIPS. The program will begin grading physicians in 2017 for changes in their payments starting 2019.

When we dig a little deeper, we find two major problems: (1) MIPS cannot measure what MACRA purports to incentivize, and (2) APMs are handwaving on a cargo cult level. Finally, MACRA, by further crapifying the physician’s workplace, will give doctors new reasons to leave the Medicare program (and for any good neoliberal, that’s not a bug. It’s a feature).

MIPS Cannot Measure What MACRA Purports to Incentivize

Here is the MIPS described in the language of health care policy:

Instead of applying the typical “one size fits all approach,” MACRA allows eligible professionals and eligible organizations to identify quality measures and then tailor the quality measures that best fit their individual practice and specialty. Eligible professionals are assessed only on the categories that apply to them, and the categories may be reweighted to compensate, as needed. Each year, the Secretary will establish a performance threshold based on the performance of all participating eligible professionals, who will be informed of how they performed in the prior period and what performance threshold they must meet to be eligible for incentive payments and to avoid penalties. Additionally, eligible professionals who [sic] scores fall into a high performance category will receive an additional bonus payment, and providers who make notable gains in performance will be rewarded.

If “Merit-based Incentive Payment System” makes you think of meritocracy gone mad, you’re not wrong. Focus on the two key words: “score,” and “categories.” I’ll look at each in turn.

Score: Yes, MIPS really does propose to “to provide each physician with a composite score between one and 100” for each individual doctor[1] Of course, this is not possible. Kip Sullivan of PNHP explains:

With the exception of a few services, measuring cost and quality accurately at the individual doctor level is not possible. There are two intractable impediments: Determining which doctor patients “belong” to (the attribution problem); and adjusting measures of physician cost and quality for factors outside of physician control such as patient health status (the risk-adjustment problem). The attribution and risk-adjustment methods used today are crude even for large groups; with the possible exception of a few of the simplest process measures, they are worthless at the individual physician level.

Categories: It seems laudable that MACRA wishes to compare apples to apples when grading physicians. The difficulty comes in with categories used to determine which physicans are apples, and which are oranges, because the sharp edges of artificial taxonomies always slice through the fuzzy complexity of real-life treatment, and because the categories can be gamed.

Here’s a “wound practitioner” lamenting the MIPS taxonomy:

How are wound care specialists supposed to compete in the market as we move toward 2018? The law states payment is “based on comparative data of similar specialty in a geographic area.” So, those family-practice physicians working only in wound care will be scored and vetted against other family-practice physicians, some of whom may not be performing wound care or treating high-risk, high-cost patients. As a result, these physicians could be subject to a negative reimbursement against one’s peers, simply because CMS does not recognize wound care as a specialty based on the taxonomy identifiers. For wound care specialists, the problem exists on one base level: CMS has not adopted any methodology as of this writing to track and manage patients living with venous disease. With an annualized cost of almost $18 billion, CMS would want to track venous disease. CMS already tracks diabetic foot ulcers ($245 billion), but venous disease has seemingly slipped through the cracks.

And here’s a firm that seems to be in the business of gaming the categories:

MACRA Series – Service Codes for Primary Care: There is More Value Than You Know

Here the codes you must know:

1. The wellness codes (IPPE, AWVs, G0402, G0438-9). In 2005, Congress instituted the Initial Preventive Physical Exam (IPPE), the “Welcome to Medicare” service code.” This service code was designed to ensure that any patient entering Medicare was provided an opportunity to “catch up” with needed screening, disease prevention and health promotion recommendations. This service code can be used within the first calendar year of a patient’s Medicare enrollment.

2. Transitional care management codes (TCM, 99495-6): These codes were designed specifically to address patient care needs after discharge from hospital, ER observation or skilled nursing care.

The wellness and TCM service codes offer substantial protection against threatened reductions that will come with MACRA (the Medicare Access and CHIP Reauthorization Act). For both, there are office workflow implications and specific roles need to be clarified and assigned. Documentation requirements are straightforward and consistent with continuity and quality patient care quality. Your electronic health record (EHR) should fully support both.

I don’t have statistics on how many doctors went into medicine so they could optimize their practice to profit from a CMS taxonomy, but my guess would be not very many. And if all this reminds you of another large-scale neoliberal debacle based on meritocratic assumptions — the “high stakes testing” regimen of No Child Left Behind — you’re not wrong about that either. Reader DCSweeney comments:

The key mechanism is reminiscent of No Child Left Behind, poor performers see their reimbursement rates cut while high performers see their reimbursements increase (+/- 9% by 2022!). The kicker is that this is zero-sum….

And all the while, the metric of “performance” is worthless. It’s as if the grades for high stakes testing were given out by throwing darts at a dartboard. And it’s going to take immense investment in paperwork for doctors to document that they’re performing to the crazypants metric! It’s a two-fer worthy of Pavlov at his best (or worst)!

APMs are Handwaving

Now let’s look at “Alternative Payment Models” (APMs). Policy and Medicine once more:

CMS proposes to establish a scoring standard for MIPS eligible clinicians participating in certain types of APMs that will reduce participant reporting burden by eliminating the need for such APM eligible clinicians to submit data for both MIPS and their respective APMs. CMS proposes to use the APM scoring standard for MIPs eligible clinicians in APM Entity groups participating in certain APMs that meet the criteria.

I hate even to think this, but CMS is giving the unfortunate impression that they’re making MIPS so crazypants and onerous to drive people into APMs. Then again, Kip Sullivan points out that nobody knows what an APM is anyhow, so it’s all handwaving:

[The APM program] is difficult to describe for these reasons:

  • MACRA does not describe the entities that will qualify as APMs;
  • MACRA sets standards for these entities that cannot be met by the vast majority of conceivable entities, including today’s most faddish APMs – ACOs and “medical homes”;
  • MACRA says APMs must expose doctors to “risk above a nominal level,” but doesn’t say what “nominal” means; and
  • MACRA says doctors who join APMs will earn a 5 percent bonus on revenues received through APMs, but the law fails to define “revenue” (options include revenue from Part A, Part B, Part D, all or some of those parts, or revenue received for particular services).

So, out of the crazypants MIPS frying pan into the unknown APMs fire. Not an enviable choice.


Do I have a better proposal? Yes. Burn down the entire edifice and hire some Canadians to show us how to do it right. Go with a system that’s simple, rugged, and proven. Stop paying all these people to harm us.


[1] And for the usual hoary old neoliberal justification. MedPage today:

Alice Rivlin, PhD, a senior fellow at the Brookings Center for Health Policy, a left-leaning [snort] think tank, called for a two-sided approach to dealing with the MACRA reforms. “We need to give patients more skin in the game if we believe accountable care organizations (ACOs) or some other payment reform is promising — patients need to know they’re in [an ACO] and they have an incentive to participate in improving the cost-effectiveness of their care. And I believe we need to move more aggressively toward competition among plans, and move deliberately but not too fast toward premium support in Medicare. We could start with competitive bidding in Medicare Advantage.”

However, she added, “We need to be sure [lambert nods head vigorously] we can make competitive bidding work, and solve the risk adjustment problem, so we don’t end up … with the sickest people in traditional Medicare.

You can see the death spiral coming, right? As all the 100s leave for boutique medicine, while Joe and Jane Sixpack are trying to decide whether picking a 73 over a 68 is worth the three-hour drive and the higher deductible. Of course, Rivlin — along with the whole “skin in the game” crowd — provides an excellent proof by example that the simple rules of neoliberalism never apply to those who write those rules.

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About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.


  1. weinerdog43

    This is zero surprise and yes the crapification is indeed a feature, not a bug.

    Mrs. Weinerdog just turned 65, and it has been amazingly difficult to just get a clear answer who is primary (Medicare or United Healthcare) in the event she has the need for any medical services. My employer has zero interest in getting involved for fear of providing incorrect advice, so you have finger pointing and foot shuffling. Thanks for nothing UHC.

    The obvious takeaway is that the system is designed to be so complicated that patients just give up and go without.

    1. Bob

      If the UHC insurance is a “Medicare supplement”, then UHC is the primary. At least that’s how my Medicare supplement works. Open enrollment is coming up very soon (Oct. 15 to Dec. 7) so you should be able to find someone at UHC willing to discuss this with you (or threaten to purchase a Medicare supplement from some other carrier).

      1. weinerdog43

        You are correct of course. My beef is that I’m trying to get written confirmation to that effect. It’s been my experience that unless it is written and confirmed, they will deny any phone conversation.

        1. DorothyT


          United Healthcare also sells Medicare Advantage plans. These are much different than Medicare Supplement or “medigap” plans. These are the ones in which you turn over your Medicare coverage to them and then select from an “Advantage” plan which vary as to additional monthly payments, deductibles, co-pays. By turning over your Med. coverage, I mean that the usual deduction from your Social Security monthly benefit is signed over to United Healthcare.

          Some or all of United Healthcare plans use the brand name of AARP.

          1. Dennis Byron

            You do not sign over “the usual deduction from your SS monthly benefit” to United Healthcare in the circumstance you describe. Everyone in Part B has his or her deduction put in the Part B trust fund. It makes no difference if you subsequently choose a public Part C Medicare Advantage health plan (or any other Part C health plan) or you choose an individually purchased private Medigap plan or you are lucky enough to have private group retirement health benefits or if you are unlucky enough to need Medicaid. Everyone one of the 53,000,000 of us who sign up for Part B have our money put in the Part B trust fund. Period

      2. beth

        Are you correct? My understanding is that Medicare is primary since if it doesn’t pay for a service, the UHC supplement doe not pay anything. After Medicare pays, then UHC has to pay the 20%.

        My advice is not to look for the least expensive option since if you have now or later need expensive services, you are covered more completely than in an Advantage plan. The Advantage plans want you to think you have better coverage with these products by including vision or hearing coverage, but if you ever need really expensive care, look out. BTW, this could have happened to me.

        Be very careful. I would not be covered with my most expensive therapy if I had chosen an Advantage plan. AARP UHC spent 2-3 years trying to get me to change over by sending me mailing that suggested that I could get addition benefits by moving to an Advantage Plan and how I could lower my cost of insurance.

        UHC increases the cost of my supplement 2-4 times a year. You get advance notice each year. I have a plan F and am very happy I chose this option. It is being phased out but grandfathered in my case.

          1. ambrit

            That info is in the fine print of the AARP yearly Prospectus. It’s just before the Note that explains how lobbyists are recompensated.

          2. John Zelnicker

            @Lambert – You did indeed miss the memo. :) AARP turned into an insurance broker at least 15 years ago. That’s when I hit 50 and started getting their membership mailings. One of the top benefits they were pushing was health insurance specifically structured for those over 50 who might have trouble getting coverage in the open market. The policies they offered were already crapified since they were targeting a higher risk cohort. They also offered Medigap policies.

            IIRC, a substantial majority of their revenue comes from insurance commissions.

        1. Marc

          I’m a doctor and have done plenty of the billing. If Medicare denies, the secondary denies and you get the bill

      3. jackiebass63

        Your first two sentenceses seem to be incorrect. As I understand it if UHC is the supplement then Medicare is the primary and UHC is the secondary. To me this means that UHC pays all or part of the Medicare deductible. Medicare determines what the payment for the service is. Then they usually pay 80%. The supplemental pays all or part of the 20%. An example would be if the charge was $150. Medicare decides it allows $100 for the service so they pay 80% or $80. Your copay is $20 and depending on your plan the supplement pays part or all of the $20. You are responsible for any part of the $100 that isn’t paid. The provider has to write off the $50 that medicare decided not to allow. This assumes that your yearly deductible is already met. There are exceptions. One would be for something like a flu shot which is paid in full a set allowed price..

        1. drb48

          That was how I originally understood it as well – until I actually used it. Medicare IS primary but my Medicare supplement insurer does NOT pay the Medicare deductible. Moreover, they have their own deductible. Once you’ve met BOTH, they’ll pay 80% of the 20% Medicare doesn’t pay. You get to pick up the rest. And if it’s not covered by Medicare they won’t cover it either. That’s 100% you. IF you can find a doctor that accepts Medicare – which is increasingly difficult. Especially if you want to see a specialist.

  2. Adam Eran

    More MBA thinking: If you can’t measure it, it doesn’t exist. So teachers are given merit raises based on test scores, etc. Thomas Franks’ Listen Liberal calls out this kind of thinking too.

    What’s hilarious about “scientific” management is that the founders of MBA schools were inspired by the likes of “efficiency expert” Frederick Winslow Taylor, who modified the results of his “experiments” to fit his hypotheses. In other words, the first MBA programs were based on a con.

    See Matthew Stewart’s The Management Myth for the whole story. The link is to an article he expanded to make a book.

    1. Lambert Strether Post author

      It takes a whole wall-full of credentials to transform throwing a dart at a dartboard into a metric.* But that’s what economists are for!

      * To be fair, it probably takes a bookcase full of books for the background in the head shots.

    2. jackiebass63

      Merit pay for teachers has been tried for decades. Research finds that teachers getting merit pay don’t perform any better than those teachers in a control group that don’t get merit pay. This is probably because there are too many variables that teachers have no control over. The same would be true for doctors. No two students are the same just like no two patients are the same.

      1. flora

        Merit pay at the VA hospitals didn’t work out too well.

        “”Here’s what the systemic problem is when you look at it all. The way they’re measuring success is by a metric that even the (Inspector General) can’t tell us how they came up with the numbers,” said Rep. Jon Runyan, R-N.J., who represents parts of Ocean County. “That’s where these secret lists come in to factor, because if they’re not in the computer system, they’re not on the clock for getting that patient seen, and so they’re cooking the books by not putting them in the computer system. Now they can get their bonuses on the back end.” ”



  3. Larry

    I would take this as another attack on labor with patients as collateral damage. Education reform to my mind is mostly about destroying the power of teachers unions. Physicians are another well paid and respected class of workers who very often have liberal political leanings. They are powerful enough to challenge the capital on issues of pay and expenditure and that power cannot be tolerated. This system is a future glimpse of the physician career being lower paid and less desirable.

    1. ProNewerDeal

      Health pros, or at least physicians, seems to be among the last occupations left, where one can reasonably expect to be able to work to retirement age (65, 67, or whatever the 0bamaPaulRyans end up crapifying it to) without significant Type 1 Overqualified Underemployment risk. In contrast, there are countless examples of engineers, accountants, PhD scientists, lawyers, etc working jobs that don’t require a BA degree, like retail, taxi driving, etc.

      Interesting to note that even the physician occupation maybe getting crapified to an extent.

    2. Lambert Strether Post author

      It would be nice to see a bit of criticism/self-criticism from the AMA on its position against “socialized medicine.”

      I remember hanging out in a Starbucks in Philly during a professional conference for doctors and overhearing American doctors querying their Canadian counterparts: “Wait, you get paid in 30 days? You don’t have to have two staffers to handle the billing?” It seemed like science fiction to them….

  4. Toolate

    2 thoughts.
    First and most importantly the evidence to support pay for performance schema is severely lacking. Indeed what we know from years of social science research is that such schema often end up destroying intrinsic motivation. And we really dont even k ow how to properly
    define quality.

    Second, if you want to better understand why we would go this route look no further than the recent past history of where the incentive payments end up going. Anyone care to guess?
    Hint: not to individual doctors.

    1. Lambert Strether Post author

      I saw mention of a study float by in the zeitgeist; the idea was set up two teams to do the same task, Team A was incentivized by money, Team B by “the joy of the game.”

      At some point, the experiments yell “Coffee break!” The group that downs tools is [drumroll] Team A.

  5. joey

    The annual ‘medicare fix’ was an annual rite of passage whereby doctors’ pay from medicare didn’t get chopped due to medicare always being over budget. This ‘fixes’ that by giving doctors impossible hoops to jump through making APMs somehow appealing despite the fact they are essentially governmental HMOs which sounds like a nightmare unto itself.

    The AMA doesn’t mind, because somehow it morphed itself from a professional organization to a multinational corporation whose main product isn’t its large number of journals but CPT billing codes, for which it owns the copyrights.

    1. ambrit

      At least you didn’t try any MACRAnomics jokes.
      There’s always the formulary used, the MACRAnomicon.
      Basically, this all falls into the category: Gallows Humour.
      Will HHS Secretary Kevorkian please pick up the black courtesy phone…

      1. juliania

        And there’s always Weapons of MACRA Destruction, (or Deception, take your pick.) I like that because it can be an acronym within an acronym within an acronym.

        At least they’ll soon be able to eliminate the fine print completely. All those teeny tiny people operating teeny tiny typewriters will be out of a job, but then they don’t make much noise; the MACRAs can hardly hear them these days as it is, what with the wind whistling around amid the high rises.

  6. Kramer

    This article has a score 58. The comments currently stand at 61 or 59 ( I’m having a bit of trouble with the calculation)

  7. flora

    if all this reminds you of another large-scale neoliberal debacle based on meritocratic assumptions — the “high stakes testing” regimen of No Child Left Behind — you’re not wrong about that either.”

    Yes. And NCLB resulted in teachers teaching to the test, instead of teaching to the student. What horrors will be produced by “treating to the MIPS test”, instead of treating to the patient’s health. (shudder)

    Great post. NC is like the DEW line (Distant Early Warning) for readers.

    1. flora

      Another tidbit on Medicare from Healthcare It News. (“meaningful use” of electronic health records is another metric used in ranking. )

      “CMS to build central repository to help with meaningful use public health reporting”

      “The Centers for Medicare and Medicaid Services is launching a central data repository for public health agency and clinical data registry reporting.

      “The database, set to be completed by 2017, will help practices and hospitals meet meaningful use requirements for public health reporting, pointing them toward agencies and registries able to accept electronic public health data.

      “To join the repository, those organizations must report on their readiness to receive electronic data by October 31. Further, qualified entities need to identify the public health measures the organization reports, such as immunization registry, specialized registry reporting, electronic case reporting and syndromic surveillance reporting.

      “Registries can use the CMS input form to join the repository, which also declares its readiness to receive public health reporting, according to officials.”

      So much more reporting. How much medical attention/care will patients get in a brief office visit?

      1. Lambert Strether Post author

        That’s a great source, thank you. This paragraph:

        Todd Cooper, principal of Breakthrough Solutions Foundry, a member of the IEEE Personal Devices* Workgroup, said that when trying to implement HIT architectures and solutions, it helps to have a definition.

        But he concedes that it would help to have one “with a bit more flesh on the bones to help direct roadmap and development planning” than the one ONC has been using. Whereas ONC has been using the IEEE definition, Cooper recommended a new one by The Center for Medical Interoperability.

    2. Jim Haygood

      Currently, about 80 percent of doctors accept new Medicare patients.

      After five years of MACRA, we should be able to cut this proportion to 60 percent or less.

      Has anyone proposed “0bamacare for all”?

      Sorry, kidding …

      1. Kokuanani

        I’d really like to see a study of “percentage of docs accepting Medicare patients” done by geographic area. As I’ve noted here many times, in the Washington DC area, it’s very hard to find such a doc, short of the crappy crowd at Kaiser. Too many patients here with high-paying insurance provided by the Feds or their private employer. Docs have no need to accept those low-rent Medicare folk.

      2. Paula

        I was stuck in Kaiser Permanente for a few years, then no health insurance for 5 yrs. Living off savings after a robbery and brutal beating, I didn’t qualify for ACA and my state didn’t expand Medicaid. Now I’m poor and need to pick a Medicare program. When I called the doctor I’d missed so much while this was going on I was told she wasn’t accepting any new Medicare patients if you hadn’t been a client for more than three years. My Medicare decision was going to be based on getting back under her care. Now I still don’t have insurance, just a lot of unopened letters asking for my Medicare payments I suppose.

    3. abynormal

      the DEW line…i love it and they are! …saved my oldest friends house back in 2010 and that’s no lie!

  8. Bob

    Patient satisfaction linked to higher health-care expenses and mortality
    “A team of UC Davis researchers found that people who are the most satisfied with their doctors are more likely to be hospitalized, accumulate more health-care and drug expenditures, and have higher death rates than patients who are less satisfied with their care.”

    “Doctors may order requested tests or treatments to satisfy patients rather than out of medical necessity….”
    “Providers who are too concerned with patient satisfaction may also be unwilling to bring up uncomfortable issues such as smoking, substance abuse or mental health, which may then go unaddressed.”
    “The study found that patients who were most satisfied had greater chances of being admitted to the hospital and had about 9 percent higher total health-care costs as well as 9 percent higher prescription drug expenditures. Most strikingly, death rates also were higher: For every 100 people who died over an average period of nearly four years in the least satisfied group, about 126 people died in the most satisfied group.”

    This study also covered in The Atlantic

    Patients are not customers and by giving them what they want (like narcotics or unneeded tests) the physician can improve his satisfaction score while the patient suffers.

    1. flora

      Interesting study. However, until I know its funding source – outside grants from who or what? UCDavis sponsored in its entirety? Joint funding among what agencies? –
      I’ll pass on letting it inform my decision making.

      1. Felix_47

        It matches my experience precisely in thousands of cases. The worst thing you can do is listen to how the patient wants to be treated……unless they went to medical school and did six years of residency afterwards. You can do law pretty much with little education but it is hard to do you own medical judgement without having treated thousands of cases.

  9. marym

    Depending on the focus of a particular discussion, if advocates for “single payer” or “Medicare for All” were to specify that their reference was to “H.R. 676 – Expanded and Improved Medicare for All” it would be easier to discuss objections and concerns about current Medicare, as the bill addresses or eliminates many such concerns. Premiums and co-pays; displaced insurance industry workers; funding mechanisms are some of these.

    In this case, it’s not really clear. There has always been the problem of reimbursement rates in H.R.676 even without issues raised by MACRA, as the bill itself wouldn’t be the place to drill down into specific services covered, service codes, and re-imbursements. The bill does specify (II.202.A-C) that payment would be fee-for-service or salary, and calls for a negotiated simplified fee schedule. However, it designates the current reimbursement schedule as a starting point, so as that gets crapified…..who knows? That starting to implement this would just add further complications to a future implementation strategy for universal, comprehensive, publicly funded Medicare for All is probably just a coincidence, right?

  10. Dennis Byron

    The problems with Medicare go back to 1965. These minor modifications made 50 years later are a nit. Medicare is bad insurance. It protects you neither on the low side (it has high co-pays and deductibles) or on the high side (it has no annual out of pocket spending limit and per-incident and lifetime limits on how much it will spend on your behalf). All the other problems start with those two design flaws followed by all sorts of workarounds in 1972, 1982, 1997, 2003 and 2010. MACRA is only an attempt to fix some of the problems in the 1997 and 2010 workarounds.

    1. joey

      True. Yet the problem is any third party payer source, including Canadian or British variations, will not actually value the health of the patient over cost savings.

  11. Richard Sklader

    I am a prisoner of the Medicare system. I am the exact type of person Medicare was initially designed for as I have multiple complex conditions and diseases. Fortunately none of my conditions are life threatening nor involve the expenditure of thousands of dollars out of pocket monthly. However, when I experience serious flare ups I require intensive medical treatment across medical disciplines and specialties and I require intensive intervention and this is where Medicare fails brilliantly since the first duty of every provider is to guarantee payment, which directly controls precisely how much and what type of treatment is received. Everything you discuss in your article has practical day-to-day application.
    I have chronic severe pain which is now classified as a disease. One of the best treatments for this is therapeutic massage, which Medicare doesn’t cover. To obtain it any good PT outfit will use an appropriate ICD 10 Code, but because of Medicare’s incredibly low reimbursement rates cuts the time allotted down so much that the strength of the treatment is lost since its pallatative value gets quickly neutrlized. Now most patients like their therapists and wanting to be nice tell their therapists when asked that yes they”re feeling a little better.
    Now my situation will be altered very soon because I will soon be settling a 17 year lawsuit and will have to pay for all related conditions with “my” Medicare Set Aside. Until it runs out I will be treated like a member of the capitalist class.

  12. jfleni

    When acronym gibberish is substituted for plain English, it’s time to just sign up
    for plain A & B medicare, hope for the best, take care of your own health (from
    witch-doctors etc who can’t be any worse),pay the medicare tax, dump all the
    docs, and wait til we get a more rational system (next day to never)!

    1. Dennis Byron

      Do not take that risk. If there were an OOP limit (there was in the 2011 Wyden-Ryan proposed plan, all Ryan proposed plans since, and in Wyden’s Sept 2016 proposed plan), you could treat plain A/B as high-deductible insurance. Many very wealthy people do a variation of that already. But for the rest of us going without the OOP limit protection along with the lifetime and per-incident limits on the high side is financial suicide. Almost 100% of the people on Medicare A/B (97% of us) or just A (2%) or just B (1%) make additional mostly private arrangements to protect themselves because plain A/B is so bad

      1. jrs

        So what private arrangements? Supplemental plans? What if one chooses an advantage plan, do they still need that?

  13. DCSweeney

    I am particularly concerned about how MACRA reimbursement changes and record keeping costs would affect medicare dependent hospitals and associated physicians in rural and inner city America (Critical Access Hospitals). Market failure led congress to zombify CAHs in the late 90’s to avoid a complete collapse of rural access so they have all sorts of special privileges re/medicare to keep them afloat.

    I actually emailed someone from CMS to find out how they would be dealt with and my answer was, unsurprisingly, “CMS is currently evaluating the comments received on the proposed and is preparing the final rule, which should be released sometime in mid-October”

  14. KYrocky

    The proposals will definitely raise the standards of health care in America since our goal is to have the most expensive, least efficient, and most difficult to access health care system in the world.

    This is just more proof: We’re #1!

  15. Archie

    I want Alice Rivlin’s wrinkled old skin in the game. Literally. Might make a nice pair of US shit kickers. Or a few pairs for that matter. Can anyone confirm that DC is at the top of the list for nuclear retaliation?

  16. Mike24

    Doctors participating in medicare will pull out. As it is now they must do electronic Rx’s or take a 2% ‘sequestration” cut to each patient seen. Currently doctors see the patient, submit the paperwork w/code & supporting documents, and get paid (a nightmare of correlation hoops in itself). To ask them further their self immolation by choosing which ‘tract’ they want – to be graded by bureaucrats so they can get paid vs. a higher payment option that has no benchmarks and no guidance its just whatever the govt feels at the time to be the ‘thing’ to base payment on will be the end of Medicare.

    There has been a number of doctors that have left Medicare since the last hoops were installed. Many who were still in Medicare went to non-par status which is just short of pulling out of the program. The next step is for doctors to get the labs and the imaging centers to give the non-participating Medicare doctors a cash price for patients that they send to these facilities. This way it goes back to actual costs and not jacked up w/middle man inflation.

    1. Lambert Strether Post author

      > “correlation hoops”

      Is this a term of art?

      * * *

      This whole thing reminds me of a reporting requirement some winger congressman imposed on Amtrak. At some point, I think long distance runs, the Amtrak cafes are required to shut down and inventory everything: The M&Ms, the almonds, the hot dogs, the beer, and so on. Of course, this takes a good hour or two and in the mean time the cafe is closed and the passengers don’t get the service. If you tracked the lost sales, both from the cafe itself, and people who decided to take the bus, and the waste of staff time, the reporting requirement is probably a money loser.

      So why do it? (1) It’s a gummint program, dammit; (2) it’s fun to mess with the heads of pointy-headed bureaucrats and (3) straight-up sabotage with privatization as the end in view. Though Democrats would decry the first two, they are totally on board with the last.

      1. Mike24

        Cash prices are dictated by Medicare if you’re taking any medicare products. So where we could offer an even lower rate we’d be in violation of Medicare rules if we did so. Thats how messed up the system is.

  17. exiled off mainstreet

    As a dual national, the best thing I inherited was Canadian nationality. As a resident the last several years I avoided thousands of dollars in expense from health insurance and Obamacare. It does not matter that soon I will turn 65, since Canadian medicare is much more comprehensive without the age limit. If I was still living in yankeedom, I’d soon be scrabbling through garbage cans to survive.

    1. sleepy

      Yeah, I’m a US citizen who becomes medicare eligible in a month. After decades of scrabbling together the money for private insurance (my present Cobra policy is well over $500/mo. which is cheap), I always had the mindset that at 65 I could relax knowing my healthcare was truly “insured”.

      I actually knew better deep down, but I suppose that if I live another 10 or 15 years I will experience the full brunt of the neo-liberalization of medicare.

      Even though it looks like my total premiums with a supplement will be about $250/mo., I fully expect coverage and care to decline.

  18. grayslady

    I don’t know how MACRA will affect me directly, but a recent incident suggests that if doctors are prohibited (due to lack of reimbursement by Medicare) from prescribing tests, it will be difficult to grade them on how effectively they are doing their jobs. Back in June, as part of the blood tests for my annual wellness visit, my doctor included a test for diabetes. At the time, Quest Diagnostics flagged the test as possibly not being covered, and, sure enough, it wasn’t covered. When I called Medicare to find out why, I was told that the claims administrator probably didn’t feel the test was necessary–even though my doctor, apparently, did feel the test was necessary. This was my first experience with Medicare rejecting a procedure that the doctor felt was necessary.

    More importantly, the woman on the phone at Medicare said something like “Since you are in Illinois, the claims are determined by National Government Services.” This was a new name to me, so I looked them up and, lo and behold, it’s a private entity owned by Anthem (Anthem now owns Blue Cross/Blue Shield and, interestingly, Wellpoint–the same Wellpoint that gave us Liz Fowler to write the Obamacare law). It seems that how Medicare claims are paid is up to the individual states, and NGS has been running around the country trying to get various states to outsource their claims activity. So, even though diabetes testing is approved by Medicare, NGS has decided that they don’t have to pay the claim. The lady at Medicare told me that, increasingly, Medicare is seeing more claims being refused than ever before. My doctor’s nurse said the same thing, as well as my gynecologist.

    As we’ve discussed on NC before, Google is absolutely useless, and the traditional media doesn’t help either. I tried to do a search to find out when Illinois handed over its Medicare claims administration to NGS and came up with nothing: plenty of information on NGS, but no information on who makes the decisions within the states, which states are using NGS, and when it was decided to use NGS. Also, I can’t seem to find who was performing the claims administration before NGS. This strikes me as a back door attempt to turn Medicare into private insurance.

    1. flora

      Your mention of BC/BS makes me wonder if the refusal was on a standard Medicare medigap plan, or a Medicare Advantage plan, or basic Medicare. This NGS thing is news to me. Thanks for the info.

      1. grayslady

        I should also have said that I only mentioned the ownership of NGS because these are people who are in the business of paying–although perhaps, more often, refusing–claims based on private insurance policies (Blue Cross, Wellpoint), not based on a public program policies like Medicare.

        1. flora

          Thanks. Had no idea this was the case. I found this on the CMS website.
          “Since Medicare’s inception in 1966, private health care insurers have processed medical claims for Medicare beneficiaries. Originally these entities were known as Part A Fiscal Intermediaries (FI) and Part B carriers. In 2003 the Centers for Medicare & Medicaid Services (CMS) was directed via Section 911 of the Medicare Prescription Drug Improvement, and Modernization Act (MMA) of 2003 to replace the Part A FIs and Part B carriers with A/B Medicare Administrative Contractors (MACs) in accordance with the Federal Acquisition Regulation (FAR). Learn more about MACs at What is a MAC. Learn more about MAC current events at What’s New.”

    2. Tim

      They are certainly taking a cut, but the deeper question is what is the racket for private payment administrators to reject claims? It must be more paperwork involved in rejecting a claim than than to accept it which would increase NGS revenue.

    3. Lambert Strether Post author

      Wall Street Journal:

      Medicare is overseen by the Centers for Medicare and Medicaid Services. But under federal law, four private companies oversee Medicare claims processing and coverage decisions involving lower-limb prosthetics. The four contractors came up with the suggestions and will approve any final changes.

      The companies behind the proposal didn’t respond to requests seeking comment or referred questions to CMS. But company officials said the proposal stems from efforts to crack down on fraudulent billing and that access to limbs won’t be curtailed. The companies are NHIC Corp., Anthem Inc.’s National Government Services, BlueCross Blue Shield of South Carolina’s CGS Administrators LLC and Noridian Healthcare Solutions LLC.

      “Under Federal law”?!?!? (That is, not a regulation?)

    4. Dennis Byron

      You write

      “It seems that how Medicare claims are paid is up to the individual states, and NGS has been running around the country trying to get various states to outsource their claims activity.”

      Sort of but not quite. Since the beginning of Medicare in 1965, private insurance companies have run Medicare (you will never hear that from a Democrat), the same insurance companies that sell private Medigap supplements and public Part C health plans. It is true that there used to be one company per state but now the country is divided into around 10 areas and the insurance companies bid every three years for the contract to run Medicare in those areas. Anthem has two or three areas as you have discovered. The others are BC of FL, BC of SC, Wisconsin Physician Services, and a few others. The information you are looking for is here:

  19. Tim

    Quote of the day:

    “…one of those “bipartisan” bills that gives you the idea that the only thing the two parties can ever agree on is screwing the rest of us.”

    I was going to add “that and spending other peoples money”, but screwing us is still the end result so your statement is comprehensive.

  20. crittermom

    This is the part that jumped out at me:
    “…all participating eligible professionals, who will be informed of how they performed in the prior period and what performance threshold they must meet to be eligible for incentive payments and to avoid penalties.”

    Penalties? If healthcare plans are already bailing because they’re not making enough money, it sounds like this will have doctors bailing out of offering Medicare coverage even faster, or is there something I’m missing?

  21. Lambert Strether Post author

    I see that through a formatting error I blew away my conclusion. Here it is:

    Do I have a better proposal? Yes. Burn down the entire edifice and hire some Canadians to show us how to do it right. Go with a system that’s simple, rugged, and proven. Stop paying all these people to harm us.

    Probably uncontroversial for NC readers, but for the record….

  22. afreeman

    Please! will NC and commenters focus on uncovering whether Medicare Advantage is more costly or less costly to provide than Traditional Medicare.

    Conventional wisdom was about to settle upon the former, then without presentation of evidence decided it (conventional wisdom) had to be the latter because if the truth is the former, there’s no reason for Advantage, no matter that Obama’s Obamacare promise “like your providers? you can keep em!” is little but a sick gallows humor joke.

    Spouse departed this world in February using Traditional Medicare with Gap Plan A. Worked very well cost-wise. What did him in was not telling his cancer doctors about the audible breathing that arrived around the time of the metastasized diagnosis, plus his disdain for coordination and teamwork—a great example of the patient being in the driver’s seat regardless of theories to the contrary.

    In contrast, my Gap Plan F escalates in cost much more than the Plan A that I observed serving my spouse well. The “existing conditions” catch 22 that the Obamacare claims to have resolved remains in Traditional Medicare Gap keeping people trapped between too much coverage (frying pan) and Advantage (the fire). But don’t get me wrong, this is heaven, compared to what is most likely to come and all too soon.

      1. afreeman

        Don’t know exactly who established the entire list of possible offerings, but each state (Insurance Commissioner, etc) selects from that list a set of Traditional Medicare Supplement packages that private providers may or must offer in their state: Plan A is the low end “Pinto” almost always offered, and Plan F is the most commonly offered “Cadillac.” The rule is one can not wait until sick to go from Plan A to Plan F at least without giving the provider a chance to up the ante with a health questionaire, which also faces anyone interested in moving in the opposite direction.
        And FYI: Open enrollment applies only to those newly reaching Medicare age OR anyone wanting to jump from one “gotcha” Advantage provider to another of the many during open enrollment season advertising what looks to be a less gotcha package—getting old is not for sissies.

  23. Irrational

    My mother-in-law is old enough for Medicare.
    She has had a terrifying sequence of her practice belittling symptoms, misdiagnosing things, calling in prescriptions based on a phone call or before tests were in – deploying some of the most powerful antibiotics left for the heck of it – and generally insisting on prescribing treatment without seeing her.
    After being bed-ridden for a week she went to the ER. Issue is sill not solved.
    I know why US health care is expensive and am thankful to be a European citizen.

  24. afreeman

    Lambert, thanks for dropping the first shoe. The WSJ fortuitously dropped the other one today: “Turn Off the Computer and Listen to the Patient” (authors: two Mass. doctors, bit doctorese, good though). Unfortunately, those interested will need to find someone with subscription to go behind the paywall and make a sharable pdf.

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